Blueprint for Resilient Relationship Couples Workshop Registration Form
The quality of our lives is the equal to the quality of our relationships.
Participant #1
First and Last Name
Date of Birth
Medicaid Number (if applicable)
Participant #2
*
First and Last Name
Date of Birth
Medicaid Number (if applicable)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Are you engaged or receiving counseling services outside of Collaborative Trauma Solutions? If yes, please explain.
Please select any/all challenges that your relationship has faced in the last 6 months:
*
Department of Human & health Services (DHS) Involvement
Law Enforcement Involvement
Addiction/Substance Use
Divorce
Communication Issues
Grief
Porn
Suicide
Blended Family
Domestic Violence
Infidelity/Cheating
Other
What would you say are the strengths of your relationship?
*
Desired Workshop date
*
Saturday July 27th from 9:30-4:30pm @ Ute Indian Museum (17253 Chipeta Rd, Montrose CO 81403)
I would like to be notified of other dates
Any Dietary Restrictions?
*
How did you find out about CTS's Blueprint for Resilient Relationship Program
*
Private Pay Option
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USD
$1200 per couple, $600 deposit if unable to pay full amount. Full cost due prior to workshop. Alternative payment plans available upon request.
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
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